Laparoscopic treatment of bowel perforation after blunt abdominal trauma (BAT) in children.

Minimally invasive techniques have now become standard for the treatment of many surgical conditions in children. There are a few studies that describe the utility of laparoscopy in BAT in children. In this article, we describe the complete laparoscopic surgical treatment of two patients after a single blunt abdominal trauma, both with bowel perforation. In both cases, the perforation was identified and closed, one laparoscopically with an ongoing suture, the second jejune perforation was closed by laparoscopic-assisted techniques. Both patients had an uneventful postoperative recovery. Therapeutic laparoscopic treatment of patients with upper gastrointestinal perforation is feasible. We hypothesize, that diagnostic laparoscopy provides important information for the treatment of children with abdominal trauma and is accompanied by improved diagnostic accuracy, reduction of nontherapeutic laparotomy rates, and a reduction of morbidity. Minimally invasive surgery in children after BAT is suitable for hemodynamic stable patients, could improve pain scores, cosmetic effect, shorter hospital stays, shorter operative times and shorter return to school/activities. However, at any point in the patients care, in case the unstable hemodynamic is encountered, exploratory laparotomy is the procedure of choice.Key words: miniinvasive surgery blunt abdominal trauma - laparoscopy bowel perforation.

[Surgical treatment of children with necrotizing enterocolitis]. / Chirurgická starostlivost' o deti s nekrotizujúcou enterokolitídou.

Necrotizing enterocolitis is an acute neonatal disease. It affects in particular premature neonates with a birth weight lower than 1500 g. Despite extensive research the etiology of the disease remains obscure. The majority of authors assume multifactorial causes. Research workers try to detect various laboratory and clinical factors which could serve as criteria for surgical intervention. The sensitivity and specificity of these tests and laboratory examinations detect the disease only in an advanced stage and in the stage of perforation of the gastrointestinal tract (GIT). The main surgical approach to the treatment of this disease remains laparotomy and resection of the necrotic portion of the gut with enterostomy. In a limited number of children resection of a portion of the necrotic gut with primary anastomosis is possible. In some very serious conditions and in infants with a birth weight below 1000 g peritoneal drainage and subsequent "second look" surgery should be sufficient. It is a disease with calls for a maximum individual approach and there are no accurate defined instructions for surgical treatment. The surgeon's experience and the standard of preoperative and postoperative care are decisive.

[Maffucci's syndrome--case report of a 5-year-old female patient]. / Maffucciho syndróm--kazuistika 5rocnej pacientky.

Maffucci's syndrome is a congenital non-hereditary syndrome characterized by a combination of dyschondroplasia (enchondromatosis) and haemangiomatosis. It is a rare disease. During the last 140 years only 200 cases were described [5]. 109 cases are described in the literature by other authors [21]. This disease is associated with a high risk of development of neoplastic processes, in particular sarcomatous transformation of enchondromatoses as well as other mesodermal and non-mesodermal malignities [13]. Based on the incidence of spinocellular haemangioendothelioma with other congenital syndromes, the presence at a young age of patients and the multicentric incidence support the assumption that spinocellular haemangioendothelioma may be the manifestation of genetically based mesodermal disease which may be associated with the picture of Maffucci's syndrome [6]. In their case-history the authors present a 5-year-old patient. They describe the clinical course and findings taking into account possible manifestations and risks associated with the disease. With regard to the low incidence of the disease and its interdisciplinary character the authors pen the question of possible causal, symptomatic or palliative treatment.

[Esophageal atresia: delayed surgical treatment of the long segment]. / Atresio oesophagi: odlozené chirurgické riesenie dlhého segmentu.

Atresia of the long segment of the oesophagus in children and its surgical treatment is frequently very complicated and is associated with a high rate of complications. The authors present a patient with a long segment of oesophageal atresia type Vogt IIIB. The distance between the oral and aboral stump was 4 cm. During the first session the authors made a thoracotomy, separated the aboral stump from the trachea and closed the opening in the trachea as well as the distal stump. Then they approximated both stumps without attempting an anastomosis and fixed them by stitches to the spine. They closed the chest and performed a gastrostomy. After eight weeks they repeated the thoracotomy and made an oesophago-oesophago end-to-end anastomosis. The patient was subjected after operation three times to balloon dilatation on account of a stricture at the site of anastomosis. He is now 18 months after operation and has no complaints and no stricture.

[Results of surgery in children with congenital megacolon]. / Výsledky operácií u detí s megacolon congenitum.

In 1974 to 1999 at the Department of Paediatric Surgery in Bratislava 142 patients aged 3 days to 14 years were treated on account of Hirschsprung's disease. Seventy-four patients suffered from the classical type of Hirschsprung's disease affecting the recto-sigmoid segment of the large bowel, in 43 the long segment of the large bowel was affected. In nineteen patients an ultrashort segment was afflicted and six patients suffered from total aganglionosis of the large bowel. In 131 patients the diagnosis was established by irrigographic examination and during operation it was confirmed by histological examination of the whole month of the large intestine. In 11 patients the diagnosis was established by peroperative collection of the whole month of the large bowel. In 43 patients the diagnosis was made during the neonatal period. All 142 patients were operated. Nineteen patients with an ultrashort segment were subjected to dorsal myectomy according to Lynn and in 121 patients a retrorectal pull-through according to Duhamel in Ikeda-Soper's modification was performed. In 99 patients before the final operation a colostomy was made, orally from an aganglionic portion of the large bowel. Twenty-two patients were treated in one session by means of a direct stapler without protective colostomy. Two patients died several days after establishment of the colostomy from anaerobic septic complications. After the final operation no death was recorded. Duhamel's operation in Ikeda-Sopor's modification is in the authors' opinion very effective in treatment of congenital megacolon, being associated with a minimum of complications and is the prerequisite for achieving excellent functional results.

[Supracondylar fractures of the humerus and disorders of circulation]. / Suprakondylická zlomenina humeru s poruchou cirkulácie.

Supracondylar fractures (SF) of the humerus are the third most common type of fractures in childhood. The highest rate of pulselessness fracture of the distal humerus is the extension-type. The aim of our treatment is to minimize potential complications. Our management of pulselessness supracondylar fracture is more aggressive compared with other dpts. 223 (100%) patients with SF were treated at the dpt. of Paediatric Surgery, University Children's Hospital in Bratislava, in the 5-year period of (1995-1999). 11 (4.93%) patients remained pulseless after reposition of bone fragments. These patients underwent surgical revision of the brachial artery. Spasms of the brachial artery (BA) occurred in six patients, a lesion of BA in three patients and thrombosis of BA in two patients. We performed revision of the brachial artery by a Fogarthy catheter in six patients--in four cases with thrombectomy. In two cases we released the vessel from bone fragments. In two patients was replaced the injured segment of the brachial artery by a venous allotransplant. Peroperative angiography was performed in six patients. We reoperated three patients with early postoperative complications. We did not record any case of Volkmann's contracture.

[Traumatic injuries of the urethra in children]. / Traumatické poranenia uretry u detí.

Authors presented their experience in diagnosis and treatment of 5 cases of traumatic rupture of urethra. Clinical symptoms of the closed type of the urethra are frequently not clear. In 70% of patients, outer urethral orifice bleeding is usually omitted. When this injury could be suspected, urethral catheterization is not recommended because it might extend level of damage. Urethrography is recommended as it would offer sufficient information on the injury. Pulling the balloon catheter to approach proximal and distal part of the injured urethra will result in creating fibrous channel between the ruptured parts of urethra however, this fibrotic part tends to develop dilatation resistant stricture.

[Personal experience in the treatment of medial cervical cysts in children]. / Nase skúsenosti s liecbou mediálnych krcných cýst u detí.

Twenty-five patients with thyreoglossal cysts were treated during a 7 years long period. Most of the cysts (in 64 of patients) were typically located between the hyoid bone and the thyreoid gland. The complete Sistrunk's operation was performed in 40% of the patients and 48% patients underwent an extirpation of thyroglossal cyst with a resection of the hyoid bone body. Three of the patients (12%) suffered a relapse. In one of the patients, this was due to the lateral cyst swapping and in two patients an incomplete extirpation of the ductus thyreoglossus remnant happened. In another patient, an iatrogenic hypothyreossis occurred. To avoid relapse, authors recommend to resect at least 10 mm of the hyoid body and 5 mm of the ductus thyreoglossus remnant behind the hyoid bone.

[Treatment of blunt injuries of the spleen in children]. / Liecba tupého poranenia sleziny v detskom veku.

The authors report study of patients with blunt splenic trauma treated at Paediatric Surgery Department in years 1991-1999. During 9 years period 50 patients (36 males, 14 females) with demonstrated rupture of the spleen were analyzed. 46 patients (92%) were treated conservatively (group A). Complications appeared in 7 patients (15.22%), rebleeding in two patients, arterio-venous fistula in early posttraumatical period in one patient and during control in one patient, fluidothorax in two patients and posttraumatic pseudocyst of the spleen in one patient. Four patients (8%) were operated (group B). Two of them submitted splenectomy, one patient was treated by splenorrhaphy and one patient by partial splenectomy. Period of the hospitalization in average lasted in group A 12,67 days, in group B 15 days. With regard to the immunologic functions of the spleen especially in childhood authors prefer conservative treatment, in case that laparotomy is inevitable authors try to preserve the spleen.

[Atresia of the large intestine]. / Atrézie hrubého creva.

The authors describe two patients with congenital atresia of the large intestine. Both patients had colostomy when neonates. A double colostomy was performed. The microcolon was dilated across the distal colostomy by physiological saline and semolina pudding to achieve dilatation of the distal portion. Occlusion of the colostomy, tapering and end-to-end colo-colo anastomosis was performed in both children at the age of four months. The passage was restored in both patients on the third day after occlusion of the colostomy. One patient had also other congenital defects, i.e. equinovarus of both feet and a defect of the atrial septum. One patient is four, the other three years old. They are doing well and have no digestive trouble.

[Diagnosis and surgical treatment of tracheoesophageal fistulas without esophageal atresia]. / Diagnóza a chirurgické riesenie tracheoezofageálnej fistuly bez atrézie pazeráka.

Tracheooesophageal fistulae (TEF) without atresia of the oesophagus cause in children relapsing respiratory diseases. The authors present diagnostic and therapeutic procedures in seven children. The symptoms of aspiration with attacks of non-productive cough and suffocation when fed were recorded in all children since birth. In five the diagnosis was made late. In four children the diagnosis was established by oesophagoscopy, in two by cinematooesophageography and in one by Fabian's test (Koop's test). All seven children were operated by a transcervical approach. After surgery all children are in a good condition and have no respiratory complaints.

[An unusual cause of respiratory failure. Bronchobiliary fistula]. / Neobvyklá pricina respiracného zlyhávania. Bronchobiliárna fistula.

The authors describe the treatment of a patient with an inborn bronchobiliary fistula. The ex post finding that the fistula had two insertions in the bronchus called in the final stage for a combined thoraco-abdominal approach with resection of the right lower pulmonary lobe with ligature of the fistula beneath the diaphragm. Although inborn bronchobiliary fistulae are very rare, they must be considered in the differential diagnosis of causes of chronic respiratory distress syndrome in children. Early diagnosis and adequate surgical treatment make it possible to prevent serious chronic cardiorespiratory disease.